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I couldn’t believe my eyes. So I asked my colleague to read to me the recent COVID-19 guidelines from the Directorate General of Health Services (DGHS), in the Union health ministry.
I couldn’t believe my ears either.
The nine-page PDF document talks about how to treat, investigate and monitor patients with a COVID-19 infection.
What are the surprises?
Surprise 1 – Asymptomatic patients: “No investigation at this stage” and “no medications are required.” No blood tests or fancy drugs for early COVID-19!
Surprise 2 – Mildly ill patients: May need investigation if symptoms persist or the patient’s condition deteriorates. Take paracetamol and cough syrup, and budesonide inhaler. No other medicine required. That is, no hydroxychloroquine, favipiravir, ivermectin, azithromycin, doxycycline, zinc or vitamins. No plasma therapy, either.
Surprise 3 – Moderately ill: Oxygen, control of comorbidities, steroids, anticoagulants. That’s it. No Coronil or 2-deoxy-d-glucose (2-DG).
Surprise 4 – Severely ill: Oxygen, steroids, anticoagulants and clear indications for tocilizumab. Clear criteria for prescribing them. Need for recruiting the hospital infection control committee.
Surprise 5 – Diagnostic tests are specifically mentioned in the guidelines. No ferritin or lactate dehydrogenase (LDH) tests after day 1. Clear indications for a chest X-ray. Irrational and rampant use of high-resolution CT (HRCT) scan heavily criticised.
In fact, there is a full page on HRCT. The document says, “Exercise extreme caution when ordering an HRCT.” There are four bullet points on why routine HRCT shouldn’t be done and four more bullet points on when HRCT shouldn’t be ordered!
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Surprise 6 – There is a full page on remdesivir and tocilizumab. The guidelines advise the exercise of extreme caution when ordering remdesivir — “as this is only an experimental drug and has a potential to harm.” The romance with remdesivir is over. This is unbelievable!
Surprise 7 – There is a full page on steroids and anticoagulants, with sensible and straightforward advice. Dexamethasone 6 mg a day, for 10 days, no tapering off, and only in hypoxic patients. Anticoagulants as a prophylactic dose, and only in moderately or severely ill patients.
Surprise 8 – There is a full page on diagnosis, treatment and monitoring of COVID-associated mucormycosis. The dose and duration of amphotericin B is clearly spelt out. The guidelines on when to switch to oral antifungal drugs are also clear.
David Sackett, the father of evidence-based medicine (EBM), would have been so happy!
The national guidelines are very impressive, and the authors deserve high praise for sticking to EBM in the national guidelines, with the conscientious, explicit and judicious use of current best evidence to make decisions for treating COVID-19.
The author originaly published the contents of this article as a Twitter thread. The tweets were compiled and published here with his permission.
S.P. Kalantri is the medical superintendent at the Kasturba Gandhi Hospital, Sevagram.